Provider Demographics
NPI:1124148176
Name:PRO ACTIVE ADVANTAGE, LLC
Entity type:Organization
Organization Name:PRO ACTIVE ADVANTAGE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:J
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-934-5880
Mailing Address - Street 1:562 SHOUP AVE W
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5029
Mailing Address - Country:US
Mailing Address - Phone:208-734-0407
Mailing Address - Fax:208-734-3534
Practice Address - Street 1:1369 E 16TH ST STE 2
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2008
Practice Address - Country:US
Practice Address - Phone:208-878-3423
Practice Address - Fax:208-878-3424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8073698Medicaid